Palliative Care Medical Group Inc

Nicholas Jauregui MD Phone (877) 830-7328 Fax (877) 830-7469 Email

Triple Aim for Wellness and Supportive Care

1)Maximize quality of care

2)Positive patient and family experience with wellness andsupportive care

3)Reduce the cost of care as a result of improved quality of care

3 Goals of a Wellness and Supportive Care Intervention that Achieve the Triple Aim

1)Guiding patients to and their familiesmeet their highest potential health and develop a medical care plan in which they find hope in realisticgoals for their medical care.

2)Manage symptoms and coordinate and assist in health care plan across care transitions

3)Patients, their families, referring physicians and other associated persons experience the positive and unique impact of wellness and supportive care has on the patients’ care plan with high satisfaction

Implementation of Supportive Care Program

1)Process of identifying appropriate patientsto receive wellness and supportive care

2)Existing clinicians and support staff educated on how to provide high quality wellness and supportive care interventions.

3)Process for measuring the quality and effectiveness of wellness and supportive care interventions with ongoing quality improvement couching in general and customized to individual clinician.

4)Identification of wellness and supportive care clinical champions for ongoing development of the wellness and supportive care consultation service.

Success of achieving wellness and supportive care goals are measured by:

1. Compare metrics before and after wellness and supportive care intervention
2. Compare metrics of patients that do to those that do not receive wellness and supportive care
3. Outcome metrics to measure:
4. Cost of care before and after utilization of wellness and supportive care
5. Cost of care of patients that access supportive care compared to controls that do not access wellness and supportive care
6. Reduction hospital length of stay and avoidable readmissions within 30 days of discharge
7. Patient family satisfaction
8. Appropriate hospice utilization
9. Location of patient death (Hospital vs. Home and Acute Care Setting vs. Hospice)
10. Symptom severity scores
11. Quality of advanced care planning including appropriate Physician Order Set for Life Sustaining Treatment (POLST) and Advanced Directives.

Supportive Care Referral Triggers

1 Unacceptable Pain for >24 hours with a potentially life limiting illness

2 Unacceptable non-pain for >24 hours with a potentially life limiting illness

3 Unexpected readmission to the hospital due symptoms out of control without life limiting illness

4 PotentialTrach/G-Tube procedure

5 Prolonged ICU stay with irreversible life limiting disease

6 Prolonged ICU stay without significant improvement

7 Intensive care length of stay > 7 days

8 G tube placement candidates

9 Defibrillator candidates

10 Prolonged ICU stay likely

11 Unexpected readmission to the hospital due poor patient/family compliance and unrealistic expectations

12 Ineligible for a liver, lung, bone marrow, heart transplant or other solid tissue organ transplantation.

13 Frequent ER visits due to symptoms with a potentially life limiting disease

14 Malignant Neoplasm Stage IV Newly Diagnosed as Stage IV

15 CHF patients stage 4 or EF less than 20-25%

16 Frequent ER visits due to symptoms without a potentially life limiting disease

17 Discharged from Hospital to SNF with life limiting illness

18 Refused Hospice Care when Hospice Care is Medically Appropriate

19 Malignant Neoplasm Stage IV with Recurrence After Failed Treatment at least once

20 Requesting or waiting for liver, lung, bone marrow, heart transplant or other solid tissue organ transplantation.

21 Diagnosis of a Definite Life Limiting Illness (Not at candidate for curative therapy)

22 POLST with medically inappropriate Full Code, Full Care or Artificial Feeding

23 Diagnosis Dysphagia with CNS abnormality (CVA,Dementia,MS,ALS) with risk of aspiration pneumonia

24 ESRD Before Dialysis

25 Patient with life limiting illness with patient and/or family with unrealistically optimistic medical expectations

26 Patient/Family/Surrogate Decision Maker with emotional, spiritual, relational distress

27 Patient with life limiting illness and has a court appointed conservator

28 Disagreement or uncertainty among patient, patient's family, clinical staff regarding major health decisions

29 Patient admitted to LTAC (long term acute care hospital) with potentially life limiting disease

30 Patient with life limiting illness and a severe mental illness such as schizophrenia, Bipolar Disorder etc.

31 Request for a second opinion or treatment for potentially life limiting illness at a university tertiary care center

32 Supportive Performance Status Scale (PPSS) <50%

33 High Risk ICD-9 codes

34 Malignant Neoplasm Stage IV Newly Diagnosed

35 Not a Medically Appropriate POLST in context of a potentially life limiting illness

36 Clinician would not be surprised if the patient died in the within 12 months or (would not survive to adulthood in children)

37 No clear appropriate surrogate decision health care decision maker

38 Malignant Neoplasm Potentially Life Limiting, but Not Stage IV

39 Supportive Performance Status Scale (PPSS) 60%

40 Diagnosis of a Potentially Life Limiting Illness

41 ESRD After Dialysis

42 CVA with Loss of Function

43 Home O2 being ordered for a patient meeting criteria for home O2

44 No Advanced Directive in context of a potentially life limiting illness

45 > 85 years of age

46 Dementia in more advanced stages with a FAST of 6 or greater

47 Newly Diagnosed Dementia in early stages

48 Lack of Goals of Care clarity and documentation